Trupanion pet insurance Claim Form - Claim Form by niusheng11


									                                                                                                                                     Claim Form

       Part A :: To be completed by pet owner
       IMPORTANT: To expedite your claim, we require all information listed below in addition to the completed claim form.
       1. Your pet’s complete medical records from both current and previous veterinary or emergency clinics.
          (If you have provided this information for a previous claim, you do not need to resubmit it.)

       2. A copy of your veterinarian’s itemized invoice.
       Name:                                                      Policy #:                           Pet's name:

       Address:                                                                                       Pet's Age:                            Pet ID#:

                                                                                                      Species:                              Sex:
                                                                                                          Cat            Dog                       Male        Female
       Telephone:                                        Preferred Contact Times:
                                                                                                          Yes         No

       Email:                                                                                         Spayed/Neutered Date (mm/dd/yy):

       Claim Total:

       I understand I am financially responsible to my veterinarian for the entire treatment. I understand that this claim may not be covered or may exceed my plan benefits.
       I authorize my veterinarian(s) to release my pet’s medical records to Trupanion. Claims must be submitted for processing within 90 days of treatment or service.

       Your signature                                                    Date (mm/dd/yy)

       Part B :: To be completed by attending veterinarian
       This pet required care due to an:                                                              Process as Claims ExpressTM
              Illness        Injury
                                                                                                Type and cause of injury OR illness diagnosis:
       Date of injury OR when illness first appeared (mm/dd/yy):

       Has this pet been seen by another vet clinic? If yes, which clinic?

                                                                                                Practice stamp or printed name of clinic:

       Has the pet owner been following your recommended routine care program?
              Yes            No

       I confirm to the best of my knowledge the above statements are true in every aspect.

       Signature of attending veterinarian                         Print name                                                                Date (mm/dd/yy)

       Part C :: Claim submission
       By toll free fax:                               By mail:                               Claims ExpressTM
      1.866.405.4536                                   Trupanion
                                                       1148 NW Leary Way
                                                                                              Vet clinics wanting to register
                                                                                              for Claims ExpressTM please call:
                                                                                                                                       Claims ExpressTM
                                                                                                                                       fax only:
                                                       Seattle, WA 98107                      1.800.569.7913                           1.866.729.2915

rev - 10.10

To top